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Home My Public Portal About6226 ROSEMEAD BLVD_Plumbing__ I WORKERS'COMPENSATION DECLARATION ®��fa ��©[�,() FOR PLUA NG PERM-T *d" ^ u V I hereby�ffirm'that I have a certificate of consent to self 76A667A insure., a certificate of Workers'Compensation Insurancd, CE 817(REV. 10/81) or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. I BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS Certified copy is filed with the county building inspec• NUMBER FIXTURE OR ITEM tion department. i @ FEE LOCALITY e ,, WATER CLOSET/ V Date Appligant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' j BATHTUB GROSS ST. AP&do le 42 COMPENSATION INSURANCE SHOWER OWNER , � r (This section need not be completod if the work involved by MAIL /� the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS � (9-Y Vez_ I certify that in the performance of the work for which thi permit is issued, I shall notemploy any person in any manne� SINK CITY �� Q ��4 TEL. NO. so as to become subject toe orkers'Compen ion Laws. DISHWASHER CONTRACTOR Dat �- ppl' CLOTHES WASHER ADDRESS r NO CE TO APPLICANT: I after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY �• TEL.NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATELIC. deemed revoked. WATER HEATER LICENSE N CLASS LICENSED CONTRACTORS//DECLARATION DISTRICT NQ. 9�i BY I hereby affirm that I am licensed urttler provisions of Chapter 9 GAS SYSTEM OUTLETS 15t ff (commencing with Section 7000)'of Division 3 of the Business OUTLETS OVER >_ and Professions Code,and my license is in full force and effect. 5 PERr SYSTEM FINAL ® VALID ON ® DATE - Zd V License Number Lic. Class 7 FIN I9 Contractor Date BY ❑ U I am exempt under Sec. LU BAP..C. for this reason Z Date: Plan check fee 1 PLUMBING PERMIT ISSUING FEE$ ' Signature TOTAL FEE G+� SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name "2 9 6 h I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): CityTel. No. # aaaaa5 I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section ) a a i 650 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY o o a i 65 .3x 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued i 0 9. 12-85 (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE bSignature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �I I I hereby affirm that I have a certificate of consent to self I 76A667A IL JI insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) AbDRING Certified copy is filed with the county building inspec- tion department. I NUMBER FIXTURE OR ITEM @ FEE LOCALITYL Date Appli4ant WATER CLOSET NlEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB S, ST. COMPENSATION INSURANCE OiWNER (This section need not be completed if the work involved by MAIL SHOWER the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner j SINK CITY TEL.NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR I Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY • TEL.NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. ,PR CESSED BY GAS SYSTEM OUTLETS I hereby affirm that I am licensed under provisions of Chapter 9 C� ` L (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL f� VALIDATION 7lv l7 f' / y D DATE z _G/ 1 a License Number Lic. Class C FINA C Contractor Date BY ❑ I am exempt under Sec. C B.&P.C. for this reason I 2�0 r u' C Plan check fee pa , Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY Plan check applicant , HOME OWNER-BUILDER DECLARATION Name (,v I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the I G (J LJ structure is not intended or offered for sale (Section 7044, Business and Professions Code). /7 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued , (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date